I was reminded today about the movie “Steel Magnolias” starring Julia Roberts as the daughter with type 1 diabetes and Shirley MacClaine as the mother. This was not a happy movie and as such, we are sincerely grateful that times have changed since the 1980’s with improved monitoring and treatment of diabetes. However, the risk of significant long-term complications cannot be ignored in our children with type 1 and type 2 diabetes.
I am often asked, “Which form of diabetes is worse, type 1 or type 2? My response has been that the two types of diabetes are equally the same but may require different treatments at different points of time. Indeed, the typical paradigm of type 2 diabetes in children is often different than the standard adult therapy. If children/adolescents develop T2DM and their Hb A1c is > 9 or 10%, we generally start basal insulin (Lantus or Levemir). Sometimes, in certain situations, we might even add bolus insulin such as Humalog, Novolog or Apidra. Or, we might use a mixed insulin combination of NPH/regular or NPH/Humalog or Novolog. We will also generally start an oral medication such as Metformin to decrease insulin resistance which will help assist with a modest weight loss. After blood sugars are considerably improved, we will then attempt to wean off insulin as soon as possible.
In the most recent issue of Diabetes Care (Diabetes Care 2014;37:436–443) “Earlier Onset of Complications in Youth with Type 2 Diabetes” by Allison Dart, Claudio Rigatto and Heather Dean, the specter of diabetes complications was highlighted. The objective of the study was to evaluate the risk in children and adolescents with T2DM. The authors looked at three groups of children aged 1-18 years of age that were identified between 1986-2007 from a clinical registry:
T2DM: 342 subjects
T1DM: 1011 subjects
No diabetes: 1710 subjects
What did they find?
- Children/Adolescents with T2DM had an increased risk of any type of complication
- Clinical factors that increased the risk included:
- Age at diagnosis
- Hb A1c
- Use of medication that protects the kidneys (reninangiotensin-aldosterone inhibitor- this was surprising to the authors)
- A genetic polymorphism (HNF-1a G319S) was protective
- Kaplan-Meier statistics noted an earlier diagnosis of kidney and neurologic complications in the group with T2DM that presented within five years of diagnosis.
- There was no difference in the development of retinopathy between the groups of T1DM and T2DM.
- Major complications that included blindness, dialysis, or even amputation began to develop 10 years after diagnosis in adolescents/young adults with T2DM
- Development of cardiovascular diseases such as heart or stroke was rare.
- Lastly, youth with T2DM had higher rates of all outcomes than children without diabetes and an “overall 6.15-fold increase risk of any vascular disease.”
What did the authors conclude?
“Youth with T2DM exhibit complications sooner than youth with T1DM. Younger age at diagnosis is potentially protective, and glycemic control is an important modifiable risk factor.” Lastly, the authors felt that the adverse association of the kidney protective medication (described above) was a “cofounder” and would need further investigation.
I will now need to modify my answer to the question posed above and acknowledge that at least in one study, complications may develop more rapidly in adolescents and young adults that are diagnosed with type 2 diabetes. However, our practice of aggressive management with insulin initially with high- risk patients will certainly continue. Indeed, one wonders if we should consider basal insulin in all patients with type 2 diabetes at diagnosis. I am certain that there will be further research in this area in view of the huge epidemic of T2DM. The key conclusion is that blood sugar control is a modifiable risk factor. Therefore, aggressive management of hyperglycemia should be the major thrust in the management of new onset T2DM in an effort to try to delay or ultimately avoid complications.
Published On: February 10, 2014